Claims Submission Ontario Health Insurance Program
Resource Manual for Physicians
 
4.4   Submission of Claims (Continued)

Cut-Off Date for Claims Submission

The ministry operates on a monthly billing cycle. Claims received by the 18th of the month will typically be processed for payment by the 15th of the following month. When the 18th falls on a weekend or holiday, the deadline will be extended to the next business day. However, if time and volumes permit, EDT claims received after the 18th will be processed for payment. Claims received after the 18th of the month may not be processed until the next billing cycle.

Claims must contain complete, valid and accurate information in order to be processed on time. Claims requiring internal review by ministry staff may have payment delayed.

The ministry recommends daily submission of claims via EDT or weekly submission via diskette.

Resubmission of Unpaid Claims

In accordance with the Health Insurance Act, all claims must be submitted within six months of the date of service. This includes original claims, resubmitted claims and Remittance Advice (RA) payment inquiries. Claims submitted more than six months following the date of service are termed stale dated claims.

Claims Requiring Documentation

The manual review indicator is a field in your medical claims billing software which allows you to inform the ministry that special attention is required to process a specific claim.

Supporting documentation should be faxed to your local ministry office when the claim is submitted.

Supporting documentation may include an operative report, or Claims Flagged for Manual Review (form 2404-84). The reasons for submitting this form as supporting documentation are listed on the form.

A Request for Approval of Payment for Proposed Surgery (form 0691-84) is another supporting document; however, it is to be submitted to your local ministry office prior to the service being rendered.

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